Bar Code Specified Surgical Pathology Workflow

1. Bar Code Specified Surgical Pathology Workflow Joy J Mammen MD; Richard Zarbo MD; Adrian Ormsby MD; J. Mark Tuthill MD Henry Ford Health System Detroit, Michigan Tuthill et al, Henry Ford Health Systen

2. ContextIntroduction • Automation of histopathology laboratory process have been difficult due to the variability: • specimen types • the expression of disease in a given patient • laboratory procedures required to arrive at pathologic diagnosis. • A key challenge has been to automate specimen labeling • Manual labeling is tedious, error prone, and inefficient. Tuthill et al, Henry Ford Health Systen

3. ContextFocus • Revolutionary changes in materials available for use in the histopathology laboratory have allowed us to address this problem, automating cassette and slide label generation • This decreases intra-lab identification errors and improves efficiency by driving workflow using bar code technology. Tuthill et al, Henry Ford Health Systen

4. Patient & Sample Identification SP processes at risk of mis-identification error Tuthill et al, Henry Ford Health Systen

5. TechnologyCassette Creation • Misys CopathPlus™ MHv 2.4 (Misys Healthcare, Raleigh, NC) LIS • Custom interface to laser cassette etchers that use Labelase ™ software, both from General Data (General Data, Cincinnati, OH). • 2 Dimensional barcodes etched on the cassettes • Cassettes are read at the microtomy stations using Dell Optiplex 745 PC (Dell, Roundrock, TX) and Symbol ™ barcode scanners (Motorola Inc., Holtsville, NY) Tuthill et al, Henry Ford Health Systen

6. TechnologyLabel Generation • Stain-resistant slide labels (Stainershield ™, General Data) on Intermec C4 (Intermec Inc., Everett, WA) direct thermal printers • A report was developed in CoPathPlus™ that retrieves stain orders for each block. Tuthill et al, Henry Ford Health Systen

7. DesignPrior to automation • Tissue cassettes were printed with human-readable identification details using the • Leica cassette printers (Leica Microsystems, Bannockburn, IL) • Required re-entering demographic and case data into dedicated software • After processing, sections were cut and mounted onto slides manually labeled with the case accession number and part number • Stains were performed based on electronic requests that were available at the histology department through the LIS • After staining, labels were batch printed from the LIS and affixed onto the corresponding slides. Tuthill et al, Henry Ford Health Systen

8. DesignAutomation • Two General Data laser cassette etchers interfaced to CoPathPlus were placed at the accessioning stations. • During accession, cassettes are etched with the case number, patient name, part type abbreviation, and a 2D barcode. • Once the block arrives at the microtomy station equipped with a PC, barcode scanner and label printer, the 2D barcode is scanned printing all slide labels for that particular block’s stain orders from the LIS. Tuthill et al, Henry Ford Health Systen

9. DesignAutomation • Labels are printed on “Stainershield” label stock, applied to the glass slide and tissue sections are cut and placed • Blocks are positively identified and slides definitively labeled prior to staining. • Manual labeling is eliminated (reduced) • Cross matching slides with labels is eliminated • Slide labels include all relevant data as well as a bar code (code 128C). Tuthill et al, Henry Ford Health Systen

10. Accession Station U-shaped Cell CoPath terminal Barcode label printer -Lab tag -Specimen containers Lab tag scanner, bar code reader Cassette etcher- 2D barcode Microtome Station U-shaped Cell CoPath terminal 2D Barcode reader -Individual cassettes Slide label printer -Chemical resistant slide labels -Print 1 cassette not batch

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16. Barcode Specified Surgical Pathology Workflow 1 2 Create Lab Tag & Specimen Container Barcodes Gross Tissue Cutting Scan container barcode to open case in CoPath CoPath Accession Scantron Lab Tag Imager Specimens 2 Tray CoPath 3 Cassette Etcher Create cassette barcode Verify created container barcode with CoPath and cassette ID Verify original Lab Tag & created barcode ID Histology Scan cassette barcode Pathologist Signout 3 - Scan slide barcode to open case in CoPath & - View scanned lab tag in ThumbsPlus 4 Microtome 4 Create chemical resistant slide labels by cassette barcode 1 Verify on cassette & slide SP# and pt. name with CoPath Verify patient name, SP # on Lab tag, slide and in CoPath

17. Patient & Sample Identification SP processes targeted by barcode to reduce human labor and mis-identification error Tuthill et al, Henry Ford Health Systen

18. Results • Most specimens received in the lab are currently being processed using this system with slide labels printed on demand at the microtomy station. • Paper labels are still utilized for slides that requiring microwave processing since the StainerShiel labels undergo degradation • Time required for labeling prostate biopsies having 36 slides was reduced from 20 minutes to 30-45 seconds Tuthill et al, Henry Ford Health Systen

19. Results • The CoPath interfaces saves time and eliminates data entry errors related to re-keying data • This saves about two minutes per case. • Thus this technology has: • saved time and effort as well as • eliminating labeling errors Tuthill et al, Henry Ford Health Systen

20. Results Post Bar Coding All Surg Path Case Mis-identifications 62% reduction all misidentifications 45 85% reduction Block & slide mis-ID 1.67% 18 0.62% 4 Pre-analytic derived Barcode 2694 cases 2877 cases Tuthill et al, Henry Ford Health Systen

21. Conclusions • Integration of the barcode technology into the histopathology labeling process has resulted in process improvement, by saving time and reducing errors. Tuthill et al, Henry Ford Health Systen